(Acute Iron Toxicity). Adv Clin Toxicol 2020, 5(2): 000185. Copyright© Mohamed Enara

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Case Report (Acute Iron Toxicity)

Mohamed Enara* Case Report Clinical Toxicology, Poison Control Center Cairo University, Egypt Volume 5 Issue 2 Received Date: May 08, 2020 Mohamed Enara, MD Clinical Toxicology, Poison Control Center Cairo *Corresponding author: Published Date: June 16, 2020 University, Cairo, Egypt, Email: [email protected] DOI: 10.23880/act-16000185

Abstract

Acute poisoning is a critical situation that needs rapid history taking, investigations and quick intervention at the Poison Control ER. Best treatment protocols should be started as soon as a diagnosis is made, but general ABC techniques should not wait for such a diagnosis. I am presenting two cases of acute poisoning attended the Poison Control Center. The case history and signs and symptoms are described. Maneuvers for acute intervention and investigations done. Outcome and recommendations for each case is documented.

Keywords: Acute Iron Toxicity; TCA Overdose

Case 1 suggestive of metabolic acidosis with high anion gap of 20. Glucose was high with WBC above normal range too. A 3 years old boy presented to the toxicology center of Cairo University, Egypt complaining of lethargy and vomitus, led to a differential diagnosis of the following; Iron bloody vomitus of acute onset. He was found under the ingestion;These findings isopropyl together alcohol with present the clinical in perfumes picture (excluded of bloody bed of the parents, lethargic and pale. The history from his by odor); aspirin ingestion(excluded initially by absence of parents revealed that he vomited twice at home just before admission, with blood in the vomitus too. Questioning in spot cleaners and removers (initially excluded due to his parents, there was no history of previous allergic absenceany aspirin of convulsions). tablet remains) Our andmain hydrogen stress was fluoride on iron presenttoxicity manifestations, and he was not under any medications. and salicylate overdose. The child was given a crystalloid The mother had a baby age 3 weeks on presentation. O/E: solution for his state of hypotension and shock. Salicylate vitals; pulse 136, BP 75/50, respiratory rate 32, and temp level was routinely done and was negative. Serum iron level was 37.3. Chest was clear to auscultation with equal sounds was 260ug/dl after 4 hours of ingestion [1]. Gastric lavage bilaterally. Neck was supple with excessive use of accessory was done again and an abdominal X-ray was requested, respiratory muscles, with no lymphadenopathy. Abdomen which showed pill fragments and concretions in the stomach. examination showed diffuse tenderness with increased After another gastric lavage session, another X-ray picture bowel sounds and no organomegaly. Rectal examination showed pill fragments were still in the stomach. At this point showed maroon bloody stools. Nailbeds were pale, hands a decision was made to do whole bowl irrigation to the case. and feet were cold and clammy. Neurological examination This was done using a polyethylene glycol solution in a dose of 500 ml/h. The child passed clear stools after about 5 hours, 3 mm symmetrically reactive. ECG was done which revealed with normal abdominal X-ray and iron serum level of 110ug/ sinusshowed tachycardia. 1+ reflexes, Gastric slow responselavage was to performedquestions. Pupilsto the child.were dl at this point. Follow up of the child before discharge was Investigations gave the initial following results: Hb 13.4 g/ done through serial liver function tests and PT which came dl; WBC 16,700/mm3; platelets 195,000/mm3; glucose was within normal range. The child was discharged on the next 194 mg/dl on random check; Na 141; K 4.2; Cl 106; PT 15.9 day, and came back for barium meal after 5 weeks to rule out sec; pH 7.23; HCO3 15; BUN 20; Creatinine 0.7. Results are scarring of the GIT [2].

Case Report (Acute Iron Toxicity) Adv Clin Toxicol 2 Advances in Clinical Toxicology

Recommendations and Conclusions charcoal was given after a protected lavage session was done through the orogastric tube. Sodium bicarbonate in a dose Whole bowl irrigation is a very useful method of of 50mEq was initiated [4]. The next ECG of the patient after decontamination in this case because of presence of about 3 hours from bicarbonate treatment showed normal concretions, and failure of repeated gastric lavage to remove QRS interval, and the pH raised to be 7.48. The patient was the pills. Repeated abdominal X-ray is indicated to follow the under medical supervision on the monitor, and no use of process of decontamination. diazepam was made owing to the absence of seizures, which could complicate a case of tricyclic antidepressant overdose. Case 2 The patient was discharged after 2 days with complete A 30 years old female was found by her friend at home before. conscious level and normal laboratory findings made the day taken to emergency department immediately. On initial Recommendations and Conclusions evaluationat 1 a.m. obtunded the patient and was unresponsive still unresponsive, on the floor. vitals She were; was BP 80/50; pulse 120; regular; temperature 37.4. Pupils were It is advised to use sodium bicarbonate quickly to correct the acidosis and wide QRS changes of the tricyclic antidepressants acute toxicity, in addition to other routine bowlfixed atsounds about and 4 mm, no unresponsiveorganomegaly to [3]. light Her with friend 2+ tendongave a maneuvers. historyreflexes. that Chest the was patient clear; was abdomen asthmatic was and soft under with hypoactive an inhaler treatment. No history of abuse, but she was also taking References medications for anxiety disorders. No other medications were known to the friend. Lab. results were taken and the 1. Gumber MR, Kute VB, Shah PR, Vanikar AV, Patel HV, et al. initial results were: ECG showed prolonged QRS of 110msec, (2013) Successful treatment of severe iron intoxication long QT interval with 120 beat/minute. WBC 9.6; Hb 14.9; with gastrointestinal decontamination, deferoxamine, and hemodialysis. Ren Fail 35(5): 729-731. platelets 420,000; Na 140; K 3.5; Cl 101; HCO3 25; BUN 18; Creatinine 1.3 and random glucose was 125. pH was 7.27; 2. Chang TP, Rangan C (2011) Iron poisoning: a literature- PCO2 52 mmHg; PO2 89. Initial management was quickly done as follows: Airway control was done and intubation was based review of epidemiology, diagnosis, and performed to the patient. Respiratory acidosis and low PO2 management. Pediatr Emerg Care 27(10): 978-985. were present and so she needed assistance in protecting the 3. Levitt MA, Sullivan JB, Owens SM, Burnham L, Finley airways. A neuromuscular blocker was used to avoid vagal PR (1986) Amitriptyline plasma protein binding: effect effects instead of succinyl choline. The patient received a of plasma pH and relevance to clinical overdose. Am J crystalloid solution for her hypotension, and the treatment Emerg Med 4(2): 121-125. was then shifted to removal of the toxic substance. The friend brought an empty bottle of a tricyclic antidepressant drug 4. Weinbroum A, Heifetz M, Bursztein S (1985) [Poisoning by tricyclic antidepressants and antidotes]. Harefuah of the patient of a wide QRS interval and the anticholinergic 109(5-6): 132-134. symptoms(tryptizol). and This unresponsiveness was coinciding with of the the patient. physical Activated findings